Download Efficacy of Cabazitaxel Treatment in Metastatic Castration Resistant

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Journal of Cancer 2017, Vol. 8
Ivyspring
International Publisher
Research Paper
Journal of Cancer
2017; 8(4): 507-512. doi: 10.7150/jca.17644
Efficacy of Cabazitaxel Treatment in Metastatic
Castration Resistant Prostate Cancer in Second and
Later Lines. An Experience from Two German Centers
Stefanie Zschäbitz1, Sonia Vallet1, Boris Hadaschik2, Daniel Debatin3, Stefan Fuxius3, Andreas Karcher3 ,
Sascha Pahernik2,4, Cathleen Spath1,5, Stefan Duensing2,5, Dirk Jäger1, Markus Hohenfellner2, Carsten
Grüllich1
1.
2.
3.
4.
5.
Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120
Heidelberg, Germany;
Department of Urology, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany;
Onkologische Schwerpunktpraxis Heidelberg, Kurfürstenanlage 34, 69115 Heidelberg, Germany;
Department of Urology, Klinikum Nürnberg, Paracelsus Medical University, Prof.-Ernst-Nathan-Str. 1, 90419 Nürnberg, Germany;
Section of Molecular Urooncology, Department of Urology, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
 Corresponding author: Carsten Grüllich, MD, PhD, Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University
Hospital, Im Neuenheimer Feld 460,69120 Heidelberg, Germany. Phone: +49 6221 5637125; Fax: +49 6221 565318; E-Mail:
[email protected].
© Ivyspring International Publisher. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY-NC) license
(https://creativecommons.org/licenses/by-nc/4.0/). See http://ivyspring.com/terms for full terms and conditions.
Received: 2016.09.20; Accepted: 2016.12.23; Published: 2017.02.11
Abstract
Purpose: Several new treatment options for patients with metastatic castration resistant prostate
cancer (mCRPC) have been approved within the last years - among them cabazitaxel (CAB),
abiraterone acetate, enzalutamide, and radium-223. The aim of this study was to assess factors
predictive for efficacy of CAB.
Methods: We analyzed all patients with mCRPC treated with CAB at our institutions between
2011 and 2016. Data were retrieved retrospectively from the electronical patient chart.
Results: 69 patients received CAB (26.1% 2nd line, 36.2% 3rd line, 37.3% >3rd line). Median overall
survival (OS) on CAB was 10.0 months (95%CI 7.1–12.9). Median progression free survival (PFS)
on CAB was 3.9 months (95%CI 3.0–4.8). There were no differences in OS and PFS regarding
treatment line of CAB (2nd vs. higher; 2nd/3rd vs. higher). Duration of remission on 1st line treatment
(> 6 months vs. </= 6 months) was associated with a longer PFS with subsequent CAB treatment
(4.1 months vs. 3.0 months (95%CI 3.0-5.2; 2.2-3.8); p=0.021). Patients with visceral metastases
had a shorter PFS (3.0 months; 95%CI 2.6-3.3) and OS (8.7 months; 95%CI 5.9-11.5) on CAB
compared to patients who had bone and/or lymph node lesions only (PFS: 5.8 months; 95%CI
3.2-8.4; p=0.014; OS: 11.7 months; 95%CI 7.5-15.9; p=0.042).
Conclusions: Results from our patient cohort suggest that a longer PFS to any 1st line treatment
for mCRPC is correlated with a longer PFS to CAB for any later line treatment. Patients with nodal
and bone metastases only had a significantly superior PFS and OS with CAB treatment than
patients with visceral metastases.
Key words: Cabazitaxel, prostate cancer, sequencing therapy, survival, castration resistance.
Purpose
Patients that suffer from metastatic castration
resistant prostate cancer (mCRPC) had few treatment
options for a long time [1]. During the last decade
major progress has been made extending the
treatment options considerably. New generation
anti-hormonal agents (NAA; abiraterone (ABI),
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enzalutamide (ENZA)) new radiotherapeutics
(alpharadin; radium-223) and a new taxan
chemotherapy (cabazitaxel (CAB)) have all been
approved and shown to be active after failure of
docetaxel (DOC) as a 2nd line therapy [2,3,4,5,6].
However, limited data are available to differentiate
patients that may benefit rather from chemotherapy
with CAB than from a NAA post DOC. Moreover,
none of these substances have been investigated in 3rd
or 4th line within a prospective randomized clinical
trial, and there is concern regarding acquired cross
resistances among them. Nevertheless, in real-world
oncology many patients receive more than two
treatment lines aiming at a cumulative survival
benefit that has yet to be confirmed. Prospective trials
with approved substances are rarely ever conducted.
Hence, retrospective analyses might help to improve
decision making and treatment processes for this
relevant patient group.
The objective of this study was to analyze all
patients from our comprehensive cancer center and
private practice who received CAB either in 2nd line or
in later lines for clinical parameters associated with a
response to CAB.
Methods
In this retrospective observational study all 69
patients with mCRPC treated with CAB at the
National Center of Tumor Diseases (NCT) and a
private practice were identified and their records
accessed through the electronic patients charts [7].
The project was approved by the local ethics
committee.
Clinical parameters assessed included Gleason
score (GS), tumor stage, location of metastases, time to
castration resistance on androgen ablation therapy,
type of 1st line therapy, type of 2nd line therapy,
response to 1st line therapy and duration of response
(prostate specific antigen (PSA) and radiographic) as
well as response and duration of response to later
lines of CAB.
Progression free survival (PFS) was evaluated
using the Prostate Cancer Working Group 2 (PCWG2)
criteria [8]. Side effects were classified according to
CTCAE dictionary version 4.0. Overall survival (OS)
was calculated from the date of start of systemic
anti-hormonal treatment and the start of CAB
treatment to the date of death or date of last follow-up
(last assessed on March 2016). Survival and
progression were calculated using Kaplan-Meier
estimates and compared using log-rank tests.
Associations between factors were evaluated using
non-parametric Kendall-tau or Pearson correlation.
Primary outcomes were the OS as well as the PFS
since initiation of CAB. Secondary outcomes were PFS
on 1st line treatment as well as correlation analyses
between treatment factors. Statistical analyses were
conducted using the SPSS v21 software.
Results
The final study population consisted of 69
patients that started systemic anti-hormonal LHRH
analogue treatment between February 1998 and
January 2015. Most of the patients received DOC as 1st
line therapy (n=52, 75.4%). Other 1st line therapies
included ABI (n=9), ENZA (n=4), ipilimumab (n=1, as
part of a clinical trial), and PSMA ligands (n=3, as part
of a clinical trial). In 2nd line, patients received ABI
(n=31), CAB (n=18), DOC (n=12), ENZA (n=5), RNA
vaccine (n=1, as part of a clinical trial), and
mitoxantrone (n=2). CAB was applied as 3rd line
treatment in 25 patients, as 4th line therapy in 19
patients, as 5th line in 5 patients, and as 6th line in 2
patients.
CAB was administered according to the protocol
that was established by the Phase-III TROPIC trial in
the majority of patients [1]. However, 17.3 % of
patients received an upfront dose-reduction (i.e. 20%
= 20 mg/m² qd22, n=9; ~30% = 17.5-18 mg/m² qd22,
n=3) due to reduced general condition (ECOG 2 or
ECOG 1 plus bone marrow dysfunction). Three
patients were treated biweekly analogue the Prosty II
trial protocol [9]. Six patients received CAB on a
weekly scheme. In four cases dose reductions were
necessary after cycles 1 (n=2), 2 (n=1) and 6 (n=1) due
to bicytopenia, respectively. All patients received
CAB in 4th line. In 3 patients, CAB regime was
changed from three-weekly to weekly after cycle 1
due to bicytopenia. Those patients had received CAB
in 3rd, 4th and 6th treatment line. Treatment was
generally well tolerated with an average of 5 cycles
(range 1-11) and a treatment duration of 3.6 months
(range 0.4-17.0). Treatment was discontinued in most
cases either due to progressive disease or when
anticipated cycles of CAB had been applied. In one
case CAB treatment was terminated due to patient
preference. In four patients treatment was
discontinued due to toxicity (neutropenic fever CTC
4° (n=2); acute renal insufficiency CTC 4° (n=1);
peripheral sensory and motor neuropathy CTC 3° in
an 88-years old individual (n=1)). Three CTC 5° side
effects were noted: Two patients died in neutropenic
sepsis (84-years old patient on cycle 1 day 11; 75-years
old patient on cycle 2 day 11). A 71-years old patient
died due to spontaneous subdural hematoma as a
result of CAB-induced thrombocytopenia. Three
patients are still on treatment. Patient characteristics
are summarized in Table 1.
Median time between the diagnosis of prostate
cancer and the initiation of androgen deprivation was
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2.0 months (95%CI 1.0-7.9). Median time to castration
resistance was 35.0 months for all investigated
patients (95%CI 26.0-43.0, Fig. 1a). Median PFS on 1st
line treatment was 7.0 months (95% CI 5.5-8.5, Fig.
1b). There were no significant differences regarding
PFS on 1st line treatment between DOC vs. any other
treatment type or GS 6-7 vs. 8-10.
Table 1. Patient Characteristics.
Parameter
Total number of patients
Age at diagnosis [years], median
Age at CAB [years], median
Gleason Score at first diagnosis
6-7
8-10
Clinical nodal status at first diagnosis
N0
N1
missing
Metastatic spread (prior to CAB treatment)
bone metastases
peritoneal metastases
lung metastases
liver metastases
brain metastases
adrenal gland metastases
CAB treatment cycles, median
Duration on CAB, median
CAB regime
25 mg/m², qd21
20 mg/m², qd21
17.5 -18.0 mg/m², qd21
16 mg/m², qd15
10 mg/m², qd8
unknown
Type of first line treatment
Docetaxel
Abiraterone
Enzalutamid*
PSMA ligand*
Ipilimumab (within clinical trial)
Type of 2nd line treatment
Docetaxel
Abiraterone
Enzalutamid
CAB
Mitoxantron
RNA vaccine* (within clinical trial)
CAB sequence
2nd line
3rd line
4th line
5th line
6th line
Mean PSA at initial diagnosis
Mean PSA at time point of castration resistance
Mean PSA at time point of CAB begin
Mean PSA at time point of progressive disease
post-CAB
PSA response in treatment period
> 30%
> 50%
> 90%
No.
69
62
69
% (Range)
100
(46 – 81)
(51 – 88)
27
42
39.1
60.9
32
33
4
46,4
47,8
5,8
59
4
14
24
3
8
5
3.6
85.5
5.8
20.3
34.8
4.3
11.6
(1-11)
(0.4-17.0)
42
9
3
3
6
6
60.8
13.0
4.3
4.3
8.7
8.7
52
9
4
3
1
75.4
13.0
5.8
4.3
1.4
12
31
5
18
2
1
17.4
44.9
7.2
26.1
2.9
1.1
18
25
19
5
2
96.2 ng/ ml
68.5 ng/ ml
453.0 ng/ml
478.8 ng/ml
26.1
36.2
27.5
7.2
2.9
(0.1-900.0)
(0.6-355.0)
(0.0-5102.0)
(0.0-5074.0)
24
20
4
34.8
29.0
5.8
Abbreviations: CAB: cabazitaxel; PSA: prostate specific antigen; PSMA: prostate
specific membrane antigen.
Median OS since start of CAB treatment was 10.0
months (95% CI 7.0–12.9). Median PFS on CAB
treatment was 3.9 months (95% CI 3.0–4.8, Fig. 2a).
There were no differences on OS and PFS on CAB
stratified for GS (6-7 vs. 8-10), age at diagnosis, age at
begin of CAB treatment, type of 1st line therapy (DOC
vs. any other), line of CAB (2nd vs. any other; 2nd/ 3rd
vs. any other), and absolute PSA prior to CAB
treatment (analyzed for percentile ranks 50; 66.7; 75)
(data not shown). A PSA decline > 50% was seen in
n=20 patients receiving CAB (29.0%). A PSA
reduction of at least 30% was noticed in n=24 patients
(24.8%). PSA decline > 50% on CAB showed a
prolonged OS (16.6 months vs. 9.2 months; 95% CI
6.0-27.3; 6.2-12.2; p=0.087) and PFS (6.9 vs. 3.0 months,
95% CI 3.7- 10.2; 2.7-3.3; p= 0.09), however not
statistically significant. Statistical significance was
reached for the larger cohort with a PSA decline of at
least 30% for OS (16.6 vs. 8.8 months; 95%CI 6.5-26.7;
6.2-11.4; p=0.039) and PFS (6.9 vs. 3.0 months; 95%CI
4.5-9.3; 2.7-3.3; p=0.03).
When stratified for PFS on 1st line therapy (< 6
months vs. > 6 months), patients with a PFS > 6
months had a significantly longer PFS on CAB in any
later treatment line that was 4.1 months vs. 3.0 months
(95%CI 3.0-5.2; 2.2-3.8; p=0.021, Fig. 2b). No
associations were noted between OS and duration of
remission on 1st treatment line. However, there was a
trend towards longer OS on CAB treatment for
patients that remained on remission on DOC > 6
months (10.6 vs. 7.6 months; 95% CI 7.8-13.4; 4.4-10.8;
p=0.051).
Patients with visceral metastases at time of CAB
initiation had a significantly shorter PFS on CAB
reaching 3.0 months vs. 5.8 months (95%CI 2.7-3.3;
3.2-8.4; p=0.014, Fig. 2c) and a shorter OS compared to
those who only had bone or/and lymph node lesions
(8.7 months vs. 11.7 months, 95% CI 5.9-11.5; 7.5-15.9;
p=0.042, Fig. 2d) whereas PFS on 1st line treatment did
not differ significantly between those two groups.
Discussion
Therapeutic options for mCRPC patients have
been greatly expanded within the last couple of years.
Beside NAAs, with CAB a novel taxane has also
entered clinical practice [10,11]. CAB has been
approved for the treatment of mCRPC in the
post-docetaxel setting as a 2nd line treatment and is
currently investigated within the FIRSTANA trial as
1st line treatment option at different dose levels.
However, in the real world CAB is often also used
post ABI or ENZA as a 3rd or 4th line therapy being
efficient in those settings [12,13,14,15]. Retrospective
single and multicenter experiences as well as
meta-analyses have come to contradicting results for
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Journal of Cancer 2017, Vol. 8
the optimal sequence of medication. While some
showed no significant differences between the
different agents used in 3rd or 4th line [16], others
pointed to a survival benefit when applying the
sequence DOC-CAB-ABI [14,17,18] or the sequence of
CAB-NAA or vice versa compared to NAA-NAA post
DOC [19]. However, no prospective randomized
clinical trial has investigated treatment outcomes
beyond 2nd line and for different sequences. In
addition, in the aftermath of the CHAARTED and
STAMPEDE trials more and more patients will have
510
received DOC in the hormone-sensitive setting raising
new questions of optimal therapeutic approaches
upon the development of castration resistant disease.
In our retrospective cohort patients with a PFS longer
than 6 months on 1st line therapy had a significantly
longer PFS on CAB irrespective of the line of
treatment. Interestingly, it has been shown before,
that cross resistance may exist between new
anti-androgens and taxanes which is in accordance
with our data [20,21].
Figure 1. a) Time between initiation of systemic LHRH treatment and the development of castration resistant disease was 35.0 months. b) PFS on 1st line treatment
independent of treatment type was 7.0 months.
Figure 2. a) Progression free survival (PFS) on cabazitaxel (CAB) as 2nd or later line treatment; median PFS was 3.9 months. b) PFS on CAB stratified for PFS on 1st
line (< 6 months vs. > 6 months). Patients with PFS1st line > 6 months had a significantly longer PFS on CAB in any later treatment line (4.1 months vs. 3.0; p=0.021).
c) PFS of patients with visceral metastases was 3.0 compared to 5.8 months when no visceral metastases were present (p=0.014). d) Overall survival (OS) of patients
with visceral metastases was 8.7 compared to 11.7 months in the absence of visceral metastases (p=0.042).
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A high GS (as defined as 8-10) was not predictive
for response to CAB as previously reported [22].
While previously published studies showed a
correlation between longer duration of remission on
first line DOC for higher GS [21,23] we could not
detect any such correlation for CAB in our cohort. We
further found no correlation between the absolute
level of PSA pre-CAB. While PSA increases during
treatment for CRPC may be flare up phenomena and
are not generally associated with radiographic
progression [4], a PSA decline is in most studies
associated with a better survival. We could also
demonstrate that statistical significance for OS benefit
was already reached with a PSA decline of at least
30%.
Large pooled retrospective analyses have
revealed that the existence of visceral metastases is a
negative prognostic factor associated with reduced OS
of 13.3 months for patients with liver metastases and
19.4 months for patients with lung metastases [24,25].
In our cohort, OS on CAB for patients with all types of
visceral metastases was 8.7 months only.
Interestingly, we also noted a significant difference in
PFS on CAB in favor for patients with bone and/or
bone and lymph node metastases compared to those
with visceral metastases in our cohort (5.8 vs. 3.0
months). A difference in PFS was not observed in 1st
line treatment when stratified for visceral metastases.
One explanation for the poor response of patients
with visceral metastases could be that clonal selection
associated with visceral spreading is associated with a
more
therapy-resistant
phenotype,
e.
g
neuroendocrine subtypes [26,27]. Biopsies from
visceral metastatic sites might help to further
genetically characterize these clones and search for
other treatment protocols. More prospective data are
required to determine if CAB is a meaningful choice
for mCRPC with visceral involvement.
We reported three grade 5 toxicities and several
treatment discontinuations and dose modifications
showing that CAB has substantial toxicity in this
elderly and frail population. It should be noted that
lower doses are equally effective with lower toxicity
[28, 29] and should be considered as initial dose level.
Limitations to our study are its retrospective
character, dual center data and small sample size that
may have introduced a bias. These factors might
explain the inability to detect survival differences due
to to inadequate power in some analyses.
Clinical Practice Points
The optimal treatment sequence for agents in
mCRPC is still unknown. Prospective clinical trials
are needed.
Conclusions
Sequencing of new substances for mCRPC
remains a subject of debate. CAB is approved for
second line therapy following DOC. However, it is
also used following new anti-hormonal treatments or
in later lines. In our analysis CAB seems to be active in
all these indications, especially if the tumor was
sensitive to any 1st line treatment, irrespective of the
line of treatment when CAB was being deployed.
However, patients with visceral metastases had a
significantly shorter OS and PFS on CAB. Prospective
studies are needed to identify the optimal treatment
sequence for patients with mCRPC.
Abbreviations
ABI: abiraterone; CAB: cabazitaxel; DOC:
docetaxel; ENZA: enzalutamide; GS: Gleason score;
mCRPC: metastatic castration resistant prostate
cancer; NAA: new generation anti-hormonal agent;
OS: overall survival; PFS: progression free survival;
PSA: prostate specific antigen; PSMA: prostate
specific membrane antigen
Acknowledgments
The NCT is supported by the German Cancer
Research Center (DKFZ), the University Hospital
Heidelberg in cooperation with the Medical Faculty
Heidelberg and by the German Cancer Aid (Deutsche
Krebshilfe). We thank the NCT registry for providing
information on survival dates.
Authors’ contributions
D Debatin: Data collection
S Duensing: Data collection
S Fuxius: Data collection
C Grüllich: Protocol/project development, Data
collection, Data analysis, Manuscript writing/editing
B Hadaschik: Data collection
M Hohenfellner: Data collection
D Jäger: Data collection
A Karcher: Data collection
S Pahernik: Data collection
C Spath: Data collection
S Vallet: Data collection, Data analysis
S Zschäbitz: Protocol/project development, Data
collection, Data analysis, Manuscript writing
Ethics Committee Approval and Patient
Consent
All procedures performed in studies involving
human participants were in accordance with the
ethical standards of the institutional and/or national
research committee and with the 1964 Helsinki
declaration and its later amendments or comparable
ethical standards. All patients provided written
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Journal of Cancer 2017, Vol. 8
informed consent. Any information connected with
the identity of individual subjects was excluded from
this study.
Consent for publication was approved by the
local ethics committee. All authors have read and
agreed on the current version of the manuscript.
Availability of data and material
Original data and material are completely
available upon requested from the corresponding
author.
Competing Interests
The authors have declared that no competing
interest exists.
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